Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Evidence-based medine and forensic pathology
- John J. Plunkett (9 February 2003)
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Medico-legal audit needed
- John A Gall (11 March 2003)
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Hutton, Kelly and the missing Epidemiology
- Yaser Adi MPH, Rouse, A (8 February 2004)
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Re: Hutton, Kelly and the missing Epidemiology
- Christopher M Milroy (8 February 2004)
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Hutton, Kelly and the missing Epidemiology
- Andrew Rouse, Yaser Adi (10 February 2004)
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Re: Hutton, Kelly and the missing Epidemiology
- Jay Ilangaratne (10 February 2004)
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Re: Re: Hutton, Kelly and the missing Epidemiology
- Geoffrey S. Sennett, Coronation Hospital, Johannesburg, South Africa (11 February 2004)
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Who, where, when and how? A second bite at the cherry.
- Alexander R W Forrest (11 February 2004)
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John J. Plunkett, Laboratory and Medical Education Director Regina Medical Center, 1175 Nininger Road, Hastings MN 55033
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Forensic pathology is unique in that it relies almost exclusively on experience and “what we were taught” rather than on testable hypotheses or controlled trials. There is no self-correction, as there is in clinical and surgical pathology. An incorrect forensic “diagnosis”, if not literally buried, is debated in Court. This is not acceptable, as Professor Milroy has stated. The EU Committee of Ministers has adopted standards for medico-legal autopsies (1). Similar standards have been proposed but not adopted in the US. However, standards address practice patterns and not belief systems. “Conviction is a greater foe of truth than is a lie.” If the belief system is flawed, no “standard” will correct the error. Forensic pathology must be subject to audit. This review must be coupled to a rigorous analysis of the “the reasoning process by which the experts connect data to their conclusions...”(2). Forensic pathology has not embraced “evidence-based “(3). The time is now. 1. COUNCIL OF EUROPE, COMMITTEE OF MINISTERS. RECOMMENDATION No. R (99) 3 OF THE COMMITTEE OF MINISTERS TO MEMBER STATES ON THE HARMONISATION OF MEDICO-LEGAL AUTOPSY RULES. (Adopted by the Committee of Ministers on 2 February 1999, at the 658th meeting of the Ministers' Deputies.) 2. Brock v. Merrell Dow Pharmaceuticals, Inc., 874 F 2nd 307 (5th Cir. 1989). 3. Donohoe M. Shaken baby syndrome (SBS) and non-accidental injuries (NAI). Am J Forens Med Pathol 2003;23 (in press). Competing interests: I frequently consult for and testify at the request of defense attorneys in infant head injury cases. |
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John A Gall, Forensic Physician Melbourne
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I agree entirely with Prof Milroy. It is, however, unfortunate that he did not extend his editorial to suggest an appropriate means for the auditing and assessment of quality in medico-legal work. Having been involved in clinical audit both within a single institution and at a national level, and now working privately, meaningful audit could be very difficult to attain. There are many reasons for this including: 1. The legal system. The adversarial system is simply one of winning or losing and not one of finding the truth. This merely encourages the use of ‘hired guns’ and brings pressure on experts from both sides to provide ‘favourable’ reports and evidence in the interests of maintaining client satisfaction and obtaining further medico-legal work. 2. The absence of evidence-based forensic medicine. Despite the long history of forensic medicine, properly conducted research in the field has been comparatively limited. This means that many of the forensic ‘facts’ are neither supported by nor based on controlled research findings but on the published personal views and experience of experts. An example of this problem is the aging of bruising where recent research has shown that past interpretations, logical thought they appeared to be, are incorrect. 3. Personalities and titles. In the relatively small field of forensic medicine, personality conflicts and favouritisms can significantly interfere in both the objective assessment of performance and the establishment of a list of accredited ‘experts’ particularly at institution level. Titles too are a problem. Chair and Associate Professorial appointments are not always indicators of either knowledge or competence although are frequently viewed as such, particularly in the courts. 4. Representation. Those providing medico-legal services are associated with a wide variety of learned societies and colleges. Most do not have effective audit systems in place and even if they did, there isn’t a uniform standard across all fields either within counties or without. 5. Assessment of court performance. Court presentation is an important aspect for any medico-legal practitioner but can this be objectively and inexpensively assessed? Audit and quality assurance programmes are certainly necessary and are long overdue but the implementation of an objective system free from bias could be very difficult. Many changes are probably needed including consideration of both national and international governing and auditing bodies that are inclusive of all medico-legal practitioners. Competing interests: None declared |
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Yaser Adi MPH, Systematic Reviewer Department of Public Health and Epidemiology, University of Birmingham, UK, B15 2TT, Rouse, A
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Twelve months ago Professor Milroy identified several important issues relating to "expert advice" and the legal system (1). For instance, a learning point from the Sally Clark case appears to be the need for the courts to hear the views of not just the traditional clinicians and forensic pathologists, but "non traditional" experts - in this case the statisticians. We believe that the publication of the Hutton report reinforces this point. We all now know that the forensic pathology advice presented in Hutton's inquiry was compatible with the view that Dr Kelly died because of a self inflicted wrist injury. However had Lord Hutton asked for expert epidemiological advice he would probably have been told: Suicide associated with wrist slashing is extremely rare - so rare that the Office of National Statistics does not report wrist slashing as a specific cause of death; it groups such deaths with other uncommon suicide methods such as belly and abdomen stabbings and throat cuttings. (see attached table). This table shows that fewer than five, 55-60 year old men use cutting and piercing instruments to commit suicide annually. This statistical evidence, combined with the fact that even after searching the medical literature (2) and speaking to medical and surgical colleagues we have not been able to document that wrist slashing can lead to successful suicide, suggests that for all practical purposes wrist slashing suicide does not exist in Britain. Suicide and self inflicted injury by cutting and piercing instruments amongst males (England & Wales) Year_______50-54_____55-59_____60-64_____65-69 1991_________2_________4_________9_________8 1992_________5_________6_________4_________1 1993_________7_________4_________6_________4 1994_________2_________3_________3_________6 1995_________6_________5_________3_________5 1996_________6_________4_________4_________5 1997_________8_________4_________3_________1 1998_________7_________7_________2_________8 1999_________5_________4_________5_________3 2000_________9_________3_________2_________4 10 yr total 57________44________41________45 Av/per year 5.7_______4.4_______4.1_______4.5 Data extracted from: Twentieth Century Mortality, The Office of National Statistics (OPCS), London 2003. How can we reconcile such conflicting opinion? The easiest way would be to discredit the epidemiological advice on the basis that it is based on inaccurate or unrepresentative OPCS statistics. This could easily be done. Would readers send us details of any 55-65 year old males, without a psychiatric history, who have committed suicide by slashing their wrist, during the last 10 years. If we fail to establish that the epidemiological evidence supports the credibility of wrist slashing suicide, we and many others will find it hard to accept that Dr Kelly died by slashing his own wrist. (1) http://bmj.bmjjournals.com/cgi/content/full/326/7384/294 (2) Ovid Medline online searched 1966 to 2003. PS: The epidemiological advice reported here was sent to the Secretariat of the Hutton enquiry on September 3rd, 2003. Competing interests: None declared |
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Christopher M Milroy, Professor of Forensic Pathology, University of Sheffield The Medico-Legal Centre, Watery Street, Sheffield, S3 7ES
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Adi and Rouse discuss the issue of the use of epidemiology and the question of self-inflicted injury. I can assure them that a man between 55 and 65 can incise his wrists and bring about his death. So can a 54 year old and a 66 year old. The problem with use of statistics in any single case is that unlikely does not make it impossible. Furthermore the toxicology showed a significant overdose of co-proxamol. The standard text Baselt records deaths with concentrations at 1.0 mg/l, the concentration found in Kelly. He also had significant ischaemic heart disease identified at autopsy. The combination of these findings is more than enough to account for the death of the unfortunate Mr Kelly. The role of the Forensic Pathologist is to assimilate all the appropriate evidence, and can consider toxicological data in the overall context. Conspiracy theories are entertaining but the reality is that whether it is the death of JFK, Diana, Princess of Wales or many of the other celebrity cases, an objective analysis does not support the conspiracy theories, which remain as fantasy only Competing interests: None declared |
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Andrew Rouse, Consultant Birmingham, B16 9PA, Yaser Adi
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We like Professor Milroy, do not like conspiracy theories. However, when we undertook our epidemiological review of wrist slash deaths we were aware that many were regurgitating the conventional wisdom that, "Bleeding to death from wrist slash injuries is well neigh impossible". We therefore sought to find evidence to substantiate or refute that "wisdom". Having spent about one hundred hours looking for data on this topic we prepared the report "Hutton, Kelly and the missing Epidemiology". We concluded that the identified evidence does not support the view that wrist slash deaths are common (or indeed possible). We are therefore pleased to note that Prof Milroy's documents the possibility of such deaths. However, before most of us will be prepared to accept wrist slashing (or any other aetiologicy) as a satisfactory and credible explanation for a death we will also require evidence that such aetiologies are likely; not merely "possible". Our report merely notes that we have not been able to find such documentation. We believe that this likeliness criterion is all-important. After all, as Prof Milroy has noted with reference to Sally Clark, one can explain away three child deaths in a family as possible murder. However unless evidence has previously been published which documents and substantiates the prior occurrence of such murders, categorising such deaths as murder is unconvincing. Similarly, we are all prepared to accept that the odd person has fallen out of an aeroplane and survived. However few of us, upon after stumbling upon a lone person on Salisbury plane, would comfortably accept his explanation - although possible - that he got there by falling from the sky. Until recently we would have been happy to downgrade our reliance on epidemiological or other data and accept expert assurance on the cause of death. However bearing in mind the Meadows expert testimony debacle, and the poor explanations for every other aspect of Dr Kelly's death we believe that the time is right for interested professionals to publish: "A case series describing 55-65 year old males, without a psychiatric history, who have committed suicide by slashing their wrist, during the last 10 years" If we cannot provide hard evidence that slash wrist suicides have occurred with some frequency - as professionals - we will only have ourselves to blame if another conspiracy theory sets hold. We are more than prepared to revise our view that wrist slash death is unlikely and will do so when evidence is published. Specifically, we would like to see case series data published by a reputable author in a peer-reviewed journal such as the BMJ. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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I have noticed the exchanges between Dr Rouse et al and Prof Milroy.In their latest response,among other things,Dr Rouse et al say,"and the poor explanations for every other aspect of Dr Kelly's death we believe that...". Chapter 5 [1] of the Hutton Report deals with toxicological,pathological, and psychiatric evidence. Paragraph 140 refers to Dr Hunt's(Home Office Pathologist)post-mortem report,an extract of which I copy below: **140. In his evidence Dr Hunt summarised his conclusions as a result of his examinations as follows: [16 September, page 22, line 22] I found that Dr Kelly was an apparently adequately nourished man in whom there was no evidence of natural disease that could of itself have caused death directly at the macroscopic or naked eye level. He had evidence of a significant incised wound to his left wrist, in the depths of which his left ulnar artery had been completely severed. That wound was in the context of multiple incised wounds over the front of his left wrist of varying length and depth....** **Other features at the scene which would tend to support this impression include the relatively passive distribution of the blood, the neat way in which the water bottle and its top were placed, the lack of obvious signs of trampling of the undergrowth or damage to the clothing. To my mind, the location of the death is also of interest in this respect because it was clearly a very pleasant and relatively private spot of the type that is sometimes chosen by people intent upon self harm. Q. We heard about investigations that have been carried out in the post-mortem and toxicology reports. A. Yes. Q. And the pathologist said that Dr Kelly's lung had been removed for tests. Have you discussed that matter with the toxicologist? A. I have discussed that matter with the toxicologist. The lung was not subjected to tests, and the rationale given to my team by the toxicologist is that the blood was tested for an entire range of substances including volatile substances and stupefying substances. No trace whatsoever was found and therefore they considered that examining the lung would not be relevant because if it was not in the blood, it would not be in the lung.** In fact,detailed reading of Chapter 5 confirms that possibility of third-party involvement including the use of volatile and stupifying substances had been explored in some detail.Further,the ulnar artery had been completely severed;whether or not self-inflicted,isn't that alone sufficient to bleed to death? With respect to Dr Rouse and others,at this stage, I find it extrmely uncomfortable in accepting their suggestion that there are "poor explanations for every other aspect of Dr Kelly's death";in fact,the evidence is wholly contrary.The epidemiological review produced by Dr Rouse et al cannot reasonably cast any doubt as to the clear post-mortem evidence in Dr Kelly's case. However,Dr Rouse and others may present more convincing evidence in the future to support that wrist-slashing and complete ulnar artery severing were not the primary cause leading to Dr Kelly's death; or if they have hitherto undisclosed evidence that suggests Dr Kelly did not commit suicide, then I am sure they will bring the matter to the attention of relevant authorities. References [1]The Hutton Report,Chapter 5. http://www.the-hutton-inquiry.org.uk/content/report/chapter05.htm Competing interests: None declared |
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Geoffrey S. Sennett, None Former Senior Anaesthetist, Coronation Hospital, Johannesburg, South Africa
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I wish to respond, sentence by sentence, to the comment made by Professor C. M. Milroy on 8 February 2004. (My response in brackets) Adi and Rouse discuss the issue of the use of epidemiology and the question of self-inflicted injury. I can assure them that a man between 55 and 65 can incise his wrists (NB plural) and bring about his death. (Not applicable to Dr Kelly's case. He had a single transected ulnar artery and from that it is alleged he died rapidly and with minimal external blood loss). So can a 54 year old and a 66 year old. (Maybe if they cut both wrists and lie in a hot bath and not outside in the open). The problem with use of statistics in any single case is that unlikely does not make it impossible. Furthermore the toxicology showed a significant overdose of co-proxamol. (Not so, according to Dr Allan, the toxicologist, who considered the co-proxamol level to be higher than "therapeutic" but not at a level found in a death by overdose, unless there were other factors involved). The standard text Baselt records deaths with concentrations at 1.0 mg/l, the concentration found in Kelly. (Maybe so, but the finding is nevertheless most unusual as a prima facie cause of death). He also had significant ischaemic heart disease identified at autopsy. (Yes and no. Dr Hunt, the forensic pathologist, stated that Dr Kelly had narrowing of the coronary arteries but is explicit that Dr Kelly did not suffer a heart attack. Thus one must assume that no changes attributable to myocardial ischaemia were actually found at autopsy. Furthermore, as evidenced by his ability to walk long distances, he had apparently excellent effort tolerance and was completely asymptomatic). The combination of these findings is more than enough to account for the death of the unfortunate Mr Kelly. (Maybe so, but this was not the opinion of Dr Hunt who attributed Dr Kelly's death to loss of blood from a cut wrist only. Moreover, he conveyed that conclusion to Assistant Chief Constable Page within minutes of his finding Dr Kelly's body and without any corroborative evidence such as a lack of blood in the heart and great vessels, at autopsy). G. S. Sennett FFARCS Competing interests: None declared |
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Alexander R W Forrest, Professor of Forensic Toxicology, University of Sheffield Medico-legal Centre, Watery Street, Sheffield S3 7ES
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On of the problems faced by Lord Hutton was that he was not able to examine witnesses on oath because of the way in which his enquiry was set up. It remains open to the Oxford Coroner to resume his inquest touching the death of the late Dr Kelly. A coroner, unlike Lord Hutton, has the power to summon witnesses and to examine them on oath so as to establish who a deceased person was and where, when how he came to his death. At the very least those who have shared their doubts about how Dr Kelly came to his death with the readers of this journal should consider also sharing their doubts and the reasons for those doubts with the Oxford Coroner. Competing interests: A R W Forrest is an Assistant Deputy Coroner who retains belief in the efficacy of the Inquest as a means of establishing the means by which a person came to their death. |
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